Consultant Pharmacist Tips: Five Steps to Safe Medication Management and Avoiding Near Misses

Consultant Pharmacist Tips: Five Steps to Safe Medication Management and Avoiding Near Misses

As consultant pharmacists, we realize medication near-misses happen more frequently than we like.  Are you doing all you can to prevent them?  In this week’s post we look at a recent event reported to the Institute for Safe Medication Practices that could have been fatal.  We will discuss what happened and give you five steps for improving patient safety.

A recently reported near-miss incident involved two sound-alike-look-alike medications, vancomycin, an antibiotic and vecuronium, a neuromuscular blocker. The order was written for the patient to receive vancomycin, but the pharmacist recognized that a vial of vecuronium had been used to prepare the dose.  The follow up investigation revealed that not only were the medications stored next to one another, the lid was missing from the bin used to store the vecuronium.

We often discuss safe medication management, but what is your organization doing to ensure your patients are as safe as possible?  Here are five steps that could have prevented this occurrence and will improve the safety of your patients:

1. Look-Alike-Sound-Alike Medications: These medications require special safeguards to reduce the risk of errors and minimize harm.  Post your organizations Look-Alike-Sound-Alike list for all staff members to see and refer to.  Make sure the list is specific to the medications you currently use.  If formulary changes are made, the list should be updated too.

2. High Alert Medications: These drugs have a higher risk of causing significant patient harm when they are used in error. Post the most recent list and ensure your staff is continuously educated on the contents of the list.  Use warning labels for both Look-Alike-Sound-Alike and High-Alert medications.  If the labels on the shelf are bent, frayed or in any way hard to read, replace them with fresh and clear versions.

3. Avoid comingling of medications: Do not store more than one medication in the same container.  They may not sound or look alike, but keeping them together greatly increases the chances that someone will pick the incorrect medication, especially when the need for the medication is emergent.

4. Give special attention to neuromuscular blocking agents: These medications require special care and any organization that stores them should develop a system to segregate, sequester, and differentiate all paralyzing agents from other medications. Additionally, they should be stored in a lidded box, when possible.

5. Provide education: Educate your staff on best practices for safe medication management.  In addition to familiarity with the list above, staff should be comfortable with brand and generic names of medications as well as ways to properly monitor patients after administration.

Safe medication management requires everyone to bring their A game.

With the growing number of FDA approved medications, the challenge increases every day.

Contact us and we will help you take steps to improve medication safety and patient care.


The Consultant Pharmacists at OctariusRx provide guidance on safe medication management, survey readiness and cost savings to ambulatory healthcare facilities/surgery centerssenior care facilities and pharmacies  We also help individual patients optimize their medications to improve their quality of life and save money. Contact us for assistance.


Any health, medical or drug information on the Web Site is for informational purposes only. This information is not intended to be used, and you should not use it, as a substitute for obtaining professional healthcare advice, diagnosis or treatment. You should always seek the advice of your doctor, a pharmacist or other qualified healthcare provider for professional healthcare advice, diagnosis or treatment for any medical condition.
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